[nhstanley]

> but come on they save lives.

I'm going to say something controversial here, but please bear with me. Your statement sort of encompasses several parts of this problem.

Some doctors are miracle workers (see [1] below), but most doctors are glorified auto mechanics. I don't say that to downplay the amount of intelligence/skill required for the job, but if you think of most doctors as "saving lives", then you obviously haven't spent a lot of time around doctors/clinics/hospitals.

Most doctors rarely save lives, and often when they do it wasn't them that really did the critical life saving steps, they're just the interface the sick person is interacting with. Most doctors deal with a series of inputs (symptoms and circumstances) and output a solution (diagnosis and remedy), which requires very little critical thinking on their part. Sick kids with the flu. Idiots that took too many drugs that need fluids, benzos, cypro, or an ice bath. People at mid-life who made shitty decisions for most of their lives and now need Lipitor/Coumadin/a treadmill/a gravestone.

The truth is most doctors get paid a lot because people erroneously assign to them the ethos of miracle workers, when most of them aren't. In fact, they often can't even do anything for their patients (see above, such kids with the flu, old people who've made shitty decisions their whole lives). The cures really come from researchers and pharma companies that come up with drugs and treatments for these incredibly difficult problems. If doctors deserve their paychecks, it's because they keep alive the illusion society wants. The illusion that when something is wrong, the doc will fix them up good. And indeed that's basically what the article is about. Doctors demand respect and to be paid to keep up the illusion and to deal with the bullshit.

[1] Obvious and important exceptions to this are ER docs and trauma surgeons, who indeed save lives. There are also clinical doctors, who work tirelessly with armies of researchers to try to find new cures for cancers, autoimmune and genetic disorders (among many other things). There are surgeons who come up with new procedures to reduce the invasiveness and trauma of procedures. These are the people that deserve the lion's share of the praise that goes towards doctors, and they should get the lions share of the money as well (some certainly do).

In this whole rant, I'm not trying to lay blame on doctors for the whole mess, because problems come from all sides, as I've hinted. Patients have unrealistic expectations of what doctors can do, the health industry is trying to low-ball doctors (not always without reason) to maximize profits, and many doctors who thought they would be genuinely helping people are realizing in reality that fate is largely decided before they even meet their patient (as a criminal lawyer friend put it, "90% of my client's case is decided before I ever meet him, but he wants me to work miracles!").

This is specifically why I didn't continue into medicine like so many of my friends. If you really want to help people, you don't become a regular doctor. You become a thoracic surgeon, or you do basic research, or you work in pharma, or you start a biotech. That's how you cure people. But no one will praise you for it.

[jrapdx3]

Practicing medicine for decades gives me some "perspective" on the subject. No one in medicine is a "miracle worker", though many of us work hard to the job responsibly.

You are wrong. We do "save lives", and not just in the ED. Every day, if not as dramatically, immediately or even noticeably, our incremental toil helps patients progress bit-by-bit toward better health. Managing chronic, debilitating conditions really does enable patients to live longer and more fully.

You are also wrong regarding income. Doctors in the US are getting paid less and less, while expenses of practice go ever higher. My own income is probably less than most of the people I know in other professions.

The "mess" of the health care system (to the extent it is even systematic) is the result of the constant assault of corporations and governments at all cost to "reduce costs", but the result has been the degradation you and others notice.

The most conspicuous evil has been perpetrated by the insurance industry. For example, amazingly short-sighted insistence on paying for a "generic" medication $3/mo cheaper than the drug already working is an every day challenge. If patients don't get what is really needed, they wind up getting sicker, need more care, the result is more money spent, not saved.

The problem is that the industrialization of medicine makes it increasingly difficult to be helpful. People are not neat little uniform units produced in factories. People are enormously complex organisms that defy all rules we invent to "explain" illness and treatment. People are unique entities that require individual attention and customized approaches if true "health care" is going to be provided.

If doctors are given the resources, time and respect to do their work, I believe almost all will strive to do it right.

[pinkyand]

> The problem is that the industrialization of medicine makes it increasingly difficult to be helpful.

Atul gawande, which is a doctor and a healthcare journalist ,and knows the medical system from inside, thinks that industrialized medicine is exactly what's needed:

http://www.newyorker.com/magazine/2012/08/13/big-med

And in general the positive results from decision support systems seem to agree with him.

[jrapdx3]

Of course, talking about the US health care "system" is hazardous given the enormous diversity of systems within it.

No doubt there are instances whereby particular "industrial" implementations function well. But there are also many that function poorly. "Industrialization" is a term that can be applied to mean numerous and distinctly different things.

I was referring to situations I've observed where doctors are restricted from taking time when necessary to evaluate complex cases. Facing a patient with several serious conditions interacting and combining is far different than dealing with a patient having one condition.

It's impossible to do the job well when "bean-counters" insist on scheduling tightly and emphasis is on "production". This is particularly problematic in primary care settings.

Having been involved in quality assurance activities for many years, I fully understand the value of consistency, adherence to rational protocols, etc. But the ability to deal with "outliers", especially when the exception is the rule, is where "industrialization" is at risk of failing.

[pinkyand]

Yes i agree, sometimes "production" goes too far. In some of those complex case it's even wiser to allocate much more time in advance from doctors and nurses, to prevent future complications - which are much more costly.

But i wonder:

On what sources do you rely when it comes to managing complex cases ? is it only known hard coded medical data in books and databases ? or also some intuition ?

And if it's intuition , how can you form intuition for such complex cases where really each case is pretty unique , as you said ?

[jrapdx3]

The ancient wisdom is the practice of medicine is as much art as science. There is "evidence" supporting many practices. As in every complex endeavor, evidence is not static, but evolving constantly.

Evidence is necessary but by itself insufficient. We must use our own power of observation combined with what we know and what we've learned to decide what to do.

So your question is indeed profound, cuts to the core of the issues. Intuition is one way to phrase it. I once heard a colleague say we're not paid because of what we know, but for the judgement we exercise about advice or treatment to offer.

Each human is indeed unique. Even identical twins are in fact not exactly the same. Rules have limits when no two cases are precisely the same, it always comes down to that very intuition you are intuitively aware of.

After all, we frequently wish to have a second opinion. I do often enough too. I like the saying, get 5 experts in a room, and you're likely to get at least 6 opinions on any subject.

Who said decisions should be easy? I sweat over each and every one.

[pinkyand]

> Who said decisions should be easy? I sweat over each and every one.

True medicine is a really hard job.

So maybe the way decide in medicine should be changed ? maybe they be done remotely but through a recommendation system so that each doctor would get plenty of nearly similar cases - so he could practice and hone it's intuition ?

Or since the complexity is really too great (and as a patient hearing that "this is art not science" isn't that encouraging , even if true) maybe the overarching goal of medicine should be to remove the art, and we finally have the tools to do it(watson, machine learning ,remote diagnosis , etc...) ?

And if we agree that that's a good goal, maybe the current way we try to do it (evidence based medicine) , is a bit clumsy due to both the science and the resistance by doctors , but at least it's going in the right directorion.

[cheald]

> For example, amazingly short-sighted insistence on paying for a "generic" medication $3/mo cheaper than the drug already working is an every day challenge.

Pardon my ignorance, but aren't generics chemically-identical compounds that simply don't carry the brand name? My "generic replacement for Norco" is still acetaminophen and hydrocodone. Indeed, the Wikipedia article on generics notes that "A generic drug must contain the same active ingredients as the original formulation", and that it must be "comparable in dosage form, strength, quality and performance characteristics, and intended use".

What am I missing that makes generics a problem?

[vacri]

The truth is most doctors get paid a lot because people erroneously assign to them the ethos of miracle workers, when most of them aren't.

They get paid a lot because they have the training to both recognise and know what to do with the edge cases. Yes, the bulk of patients can be treated with the same steps, and the nursing staff can do most of that stuff without problem. But doctors are there to watch for the edge cases, and for odd cases, discuss it with their peers. Regular meetings where doctors go over uncommon issues patients are having - you may not see it when you're on the ward itself, but it's part of the process, spreading the diagnostic load, keeping skills up, and improving outcomes for the patient.

If you really want to help people, you don't become a regular doctor.

A friend's father stopped being a gynaecologist and returned to family-practise GP, because he felt like he could help people better that way, and keep himself more interested in medicine because it was more diverse an environment. In neither environment was he saving lives, but he was still helping people. The two are not synonymous.

Your comment comes off as personally bitter, and I think insulting to folks like GPs who do help people even if they aren't literally saving lives as part of daily practice. You also seem to have conflated 'finding new cures' with 'what a doctor does', the latter of which has a lot of 'applying found cures' to it, and certainly helps people.